RELATIVE À UN ACCIDENT DU TRAVAIL GRAVE

ENQUÊTE DU COMITÉ D'HYGIÈNE, DE SÉCURITÉ ET DES CONDITIONS DE TRAVAIL
N° 61-2256
RELATIVE À UN ACCIDENT DU TRAVAIL GRAVE
Direction départementale
du travail, de l'emploi
et de la formation
professionnelle
(Arrêté du 15 septembre 1988 modifiant l'arrêté du 8 août 1986 - Code du Travail : art. L 236.7 alinéa 5)
Fiche à adresser dans les 15 jours à l'Inspecteur du Travail, en double exemplaire
L'ÉTABLISSEMENT
Nom ou raison sociale de l'entreprise :
Adresse de l'établissement :
Activité économique :
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________bvbv______________________________________________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
Code APE :
Effectif du personnel occupé :
LA VICTIME
Nom (suivi du nom d'épouse, s'il y a lieu), Prénom :
Nationalité : française
C.E.E.
autre
Ancienneté dans le poste :
Poste occupé :
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Date de naissance :
J
M
A
Sexe : F
Ancienneté dans la profession (si possible) :
M
Date d'embauche :
J
M
A
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Si la VICTIME est un salarié
mis à disposition par une
entreprise extérieure ou un
salarié d'une entreprise de
travail temporaire
Nom ou raison sociale de l'entreprise :
Adresse :
_____________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Activité économique :
_______________________________________________________________________________________________________________________________________________________
Code APE :
L'ACCIDENT
Date :
Heure :
J
M
A
h
m
Lieu de l'accident :
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Circonstances détaillées de l'accident :
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Nature, siège et conséquences des blessures produites par l'accident :
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
L'ENQUÊTE DU COMITÉ D'HYGIÈNE, DE SÉCURITÉ ET DES CONDITIONS DE TRAVAIL
Analyse des causes de l'accident :
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Mesures préconisées en vue d'en éviter le retour (et notamment actions de formation appropriées) :
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Nom et qualité des personnes ayant effectué l'enquête :
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Signature du président,
le chef d'établissement ou son représentant
Date de l'enquête :
J
M
A
Signature du représentant du personnel
au comité d'hygiène, de sécurité et des conditions de travail
ENQUÊTE DU COMITÉ D'HYGIÈNE, DE SÉCURITÉ ET DES CONDITIONS DE TRAVAIL
N° 61-2256
RELATIVE À UN ACCIDENT DU TRAVAIL GRAVE
Direction départementale
du travail, de l'emploi
et de la formation
professionnelle
(Arrêté du 15 septembre 1988 modifiant l'arrêté du 8 août 1986 - Code du Travail : art. L 236.7 alinéa 5)
Fiche à adresser dans les 15 jours à l'Inspecteur du Travail, en double exemplaire
L'ÉTABLISSEMENT
Nom ou raison sociale de l'entreprise :
Adresse de l'établissement :
Activité économique :
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
Code APE :
Effectif du personnel occupé :
LA VICTIME
Nom (suivi du nom d'épouse, s'il y a lieu), Prénom :
Nationalité : française
C.E.E.
autre
Ancienneté dans le poste :
Poste occupé :
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Date de naissance :
J
M
A
Sexe : F
Ancienneté dans la profession (si possible) :
M
Date d'embauche :
J
M
A
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Si la VICTIME est un salarié
mis à disposition par une
entreprise extérieure ou un
salarié d'une entreprise de
travail temporaire
Nom ou raison sociale de l'entreprise :
Adresse :
_____________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Activité économique :
_______________________________________________________________________________________________________________________________________________________
Code APE :
L'ACCIDENT
Date :
Heure :
J
M
A
h
m
Lieu de l'accident :
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Circonstances détaillées de l'accident :
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Nature, siège et conséquences des blessures produites par l'accident :
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
L'ENQUÊTE DU COMITÉ D'HYGIÈNE, DE SÉCURITÉ ET DES CONDITIONS DE TRAVAIL
Analyse des causes de l'accident :
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Mesures préconisées en vue d'en éviter le retour (et notamment actions de formation appropriées) :
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Nom et qualité des personnes ayant effectué l'enquête :
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Signature du président,
le chef d'établissement ou son représentant
Date de l'enquête :
J
M
A
Signature du représentant du personnel
au comité d'hygiène, de sécurité et des conditions de travail
I. 951 001 – IMPRIMERIE NATIONALE
ENQUÊTE DU COMITÉ D'HYGIÈNE, DE SÉCURITÉ ET DES CONDITIONS DE TRAVAIL
N° 61-2256
RELATIVE À UN ACCIDENT DU TRAVAIL GRAVE
Direction départementale
du travail, de l'emploi
et de la formation
professionnelle
(Arrêté du 15 septembre 1988 modifiant l'arrêté du 8 août 1986 - Code du Travail : art. L 236.7 alinéa 5)
Fiche à adresser dans les 15 jours à l'Inspecteur du Travail, en double exemplaire
L'ÉTABLISSEMENT
Nom ou raison sociale de l'entreprise :
Adresse de l'établissement :
Activité économique :
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________
Code APE :
Effectif du personnel occupé :
LA VICTIME
Nom (suivi du nom d'épouse, s'il y a lieu), Prénom :
Nationalité : française
C.E.E.
autre
Ancienneté dans le poste :
Poste occupé :
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Date de naissance :
J
M
A
Sexe : F
Ancienneté dans la profession (si possible) :
M
Date d'embauche :
J
M
A
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Si la VICTIME est un salarié
mis à disposition par une
entreprise extérieure ou un
salarié d'une entreprise de
travail temporaire
Nom ou raison sociale de l'entreprise :
Adresse :
_____________________________________________________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Activité économique :
_______________________________________________________________________________________________________________________________________________________
Code APE :
L'ACCIDENT
Date :
Heure :
J
M
A
h
m
Lieu de l'accident :
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Circonstances détaillées de l'accident :
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Nature, siège et conséquences des blessures produites par l'accident :
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
L'ENQUÊTE DU COMITÉ D'HYGIÈNE, DE SÉCURITÉ ET DES CONDITIONS DE TRAVAIL
Analyse des causes de l'accident :
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Mesures préconisées en vue d'en éviter le retour (et notamment actions de formation appropriées) :
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Nom et qualité des personnes ayant effectué l'enquête :
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Signature du président,
le chef d'établissement ou son représentant
Date de l'enquête :
J
M
A
Signature du représentant du personnel
au comité d'hygiène, de sécurité et des conditions de travail
I. 951 001 – IMPRIMERIE NATIONALE